Employment Application

APPLICATION FOR EMPLOYMENT
All applications are kept on file for seven (7) days, after that you must reapply. Employment is contingent upon passing a drug test.
Date
MM slash DD slash YYYY
Referred By
Personal Information
Name (last, first, middle initial)
Present Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone
Cell Phone
Employment Desired
Position
Date you can start
MM slash DD slash YYYY
Availability
- Full Time Only
- Part Time Only
- Full or Part Time
Salary Desired
Do you have any medical conditions that would prevent you from performing the duties of the position you are applying for? (If Yes, Please explain)
Are you currently employed?
- Yes
- No
If yes, may we contact your current employer?
- Yes
- No
Have you ever applied to Patterson Horth, Inc. before?
- Yes
- No
If yes, when?
MM slash DD slash YYYY
How did you hear of this position?
Education
High School
Name of School
Location
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Number of years completed
Major or Degree
College
Name of School
Location
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Number of years completed
Major or Degree
Business or Trade School
Name of School
Location
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Number of years completed
Major or Degree
Professional School
Name of School
Location
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Number of years completed
Major or Degree
Previous Employment
Employer 1
Employer Name
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Pay/Salary Start
Pay/Salary Final
Supervisor Name
Supervisor Phone Number
Job Description
Reason for leaving (be specific)
Employer 2
Employer Name
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Pay/Salary Start
Pay/Salary Final
Supervisor Name
Supervisor Phone Number
Job Description
Reason for leaving (be specific)
Employer 3
Employer Name
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Pay/Salary Start
Supervisor Name
Supervisor Phone Number
Job Description
Reason for leaving (be specific)
References
Give below the names of three persons not related to you whom you have known for at least one year.
Reference 1
Name
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Relationship
Years Known
Reference 2
Name
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Relationship
Years Known
Reference 3
Name
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Relationship
Years Known
Military
Branch
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Rank at discharge
Type of discharge
If other than honorable, explain
Do you have a valid Driver's License?
- Yes
- No
Do you have dependable transportation which will allow you to get to and from jobsites within 60 miles of Indianapolis?
- Yes
- No
Driver License Number
State of Issue
Expiration Date
MM slash DD slash YYYY
License Type
- Operator
- Commercial (CDL)
- Chauffeur
Have you had any accidents during the past three years?
- Yes
- No
If yes, how many?
Have you had any moving violations during the past three years?
- Yes
- No
If yes, how many?
Have you ever been arrested for a crime or crimes?
- Yes
- No
Have those arrests resulted in a conviction or convictions?
- Yes
- No
Explain arrests, conviction(s), nature of offense(s) leading to arrests or conviction(s), how recently such offense(s) was/were committed, sentence(s) imposed, and type(s) of rehabilitation.
I certify that my answers on this application are true and complete to the best of my knowledge. I also certify that all information contained within my resume (if provided) is true and complete to the best of my knowledge.

If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.

I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from all liability for any damage that may result from utilization of such information.